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A personality disorder, according to Beck and Freeman (2006), is a pattern of behaviour, perception and thought that are inflexible and permanent. It is this rigidity that inhibits the person from having a stable and fulfilling relationship with themselves and the external world. Personality disorders typically arise in adolescence and continue through to adult life. The increase in research into this area, sheds light on a bleak diagnosis, with new studies suggesting the potential for satisfactory and stable relationships despite the diagnosis in the long term (Links et al., 1990 and Stone, 1993).  

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Borderline Personality Disorder (BPD) is one of the most know personality disorders and is a complex and multilayered disorder that interacts with a persons psychological, physiological and environmental factors. In accordance with the Diagnostic and Statistical Manual of Mental Health Disorders (DSM-5), is one of six personality disorder that is predominantly categorised by impairments to ones self and interpersonal functioning with the addition of specific traits. These include Impairments in personality functioning (identity or self-direction) and interpersonal functioning (empathy or intimacy). The coinciding traits are Negative Affectivity; this includes emotional liability, anxiousness, separation insecurity, depressivity;  Disinhibition, which consists of impulsivity and risk taking; Antagonism which is characterised by hostility. These criteria and behaviours must remain consistent regardless of situation and stable across time and not solely due to external causes e.g. substance misuse.  

The actual term of a ‘borderline’ is very controversial. One side of the debate believed BPD to be a form or subtype of schizophrenia, however, others believed it was a condition that lay in-between neurosis and psychosis (Dawson and McMillian, 1993). This uncertainty could give rise to confusion in clients with the diagnosis, because they were considered to be “sicker than neurotic but not sick enough to be classified as psychotic” (Milton, 2000). This labelling and diagnosing could be seen as counterproductive, as the whole reason behind BPD was that the clients did not fit into previous categories and seems in opposition to psychology and Counselling Psychologists as a whole who are now trying to adopt a more social constructionist stance. The formation of the BPD criteria, built upon from Grinker and Gunderson’s common characteristics led to the diagnosis of BPD in the DSM third edition and its more current versions (Mayes and Horwitz, 2005).

This is in comparison to the European version, which is the International Classification of Diseases (ICD-10;WHO, 1992), that has the umbrella term, Emotionally Unstable Personality Disorder (F60.3) which splits into 2 types: Impulsive type (F60.30) and Borderline type (F60.31). (ICD-10,1992). For a diagnosis of Borderline type in the ICD-10, the client must meet the general criteria for a personality disorder, in addition to three symptoms from the Impulsive type, plus an addition two symptoms under the Borderline type, which include uncertainty around self-image, acts of self-harm and feelings of emptiness. 

In Europe, studies have shown that between 75% and 90% of a forensic population have a personality disorder and of this percentage approximately two thirds was BPD (Hildebrand and Ruiter, 2004; Ruiter and Greeven, 2004; Young-Tineo, 2005;2007). Further studies have shown a differentiation in the prevalence of BPD in men and women, portraying a higher diagnosis in the latter (Allik, 2005). Much like the comorbidity of depression and anxiety, a BPD diagnosis scarcely presents on its own. A study by the National Education Alliance for Borderline Personality Disorders highlighted the presence of other disorders such as substance misuse, antisocial personality disorder and depressive disorders (NAMI, 2006). This has resulted in the actual diagnosis being hard to detect or even mistaken for other disorders. 

What are the causes?

The vast research into the aetiology of BPD provides us with broad framework of potential reasons for the development of this disorder, reasons under psychological, biological and social. 
In terms of psychological causation: insecure attachment style (Zanarini and Frankenburg, 1997), childhood trauma (Van der Kolk et al, 1994), socio-emotional (Barnow et al., 2009) and lack of a robust sense of self (Goldstein 1996) all seem to hold one key to such a complex question; why do clients develop BPD? Van der Kolk et al (1994) found that BPD clients have difficulty regulating their emotions, which could be linked to any trauma experienced at a young age. This research seems to be supported by statistics showing that approximately 87% of BPD clients have unfortunately experienced some form of trauma, with the predominant forms being that of sexual and physical abuse (Perry and Herman, 1993). However, it is important to mention that the age at which the abuse occurred in childhood is a key factor. A lack of cognitive processing and understanding due to immaturity does not allow a child to full integrate the trauma with their experience. This can lead to different degrees of severity and psychological development, the younger the child the worse the impact (Van der Kolk et al., 1994) and gives professionals more of an insight into the causes and reasons for specific behaviours. 

Secondly there are the social factors for BPD development. Social constructionists believe that it is through our social context and societal forces that BPD became apparent. A failed sense of identity or underdevelopment due to social structures and rules being thrust upon individuals has led to disturbances in the development of personalities (Jorgensen, 2006). Individuals who have goals of self-determination and autonomy can come into conflict with societies that exert and ‘overcontrol’ through taboos and acceptable behaviours. This dissonance can lead to conflict within the individual and contribute to the personality instability. Changes in our social world, specifically rapid changes, that effect families and communities have also been speculated to have a negative effect on individuals. Millon (1995) uses the biological-psychological-social factors as the reasoning behind abnormal development thus resulting in identity underdevelopment. Furthermore, Linehan (1993) suggested that emotional instability due to childhood environments are important contributing factors. Children in an invalidating environment who are not able to cope with increased levels of frustration  can result in said child not knowing how to actually feel in their environment as their emotional responses did not receive validation. In this bleak view, Linehan did highlight that through community unity and action, these potentially maladaptive behaviours could be rectified. 

Lastly, with regards to biological factors, twin studies have portrayed a genetic basis in BPD developing due to certain characteristics such as impulsivity and affective instability, which are two of the contributing factors to a potential BPD diagnosis, being traits that have been passed down through generations (Livesley et al., 1998). Moreover, studies on the characteristics of BPD such as aggression, have been shown to be caused by a predisposing genetic vulnerability (Siever, Torgensen and Gunderson, 2002). According to Rutter (1987)), it is these types of ‘temperamental characteristics’ that can link to instability in personality. However, the majority of these studies were not able to demonstrate conclusive biological markers, therefore it is generally believed that biological factors are not the sole cause for the development of BPD. Due to the multilayered natural of the condition the likelihood of the origin being singularly linked to one aspect is slim. Each theory has focused on an aspect of an individuals development, however it is more likely that a complex combination of psychological, social and biological factors are to blame. 

Due to the increased exposure of a BPD diagnosis in clients, there has been a vast amount of literature and research on this disorder. Prevalent topics such as self-harming (Gunderson et al.,2007) and the effectiveness of interventions such as Dialectical Behavioural Therapy (Linehan et al., 1991) have been explored. Furthermore, delving into the mechanisms of BPD, Goldstein (1996) highlighted the clients’ sense of self is a central theme and key component. The lack of consistency in self and other areas in life such as people and relationships, give rise to defence mechanisms and maladaptive thinking styles which further exacerbate ‘splits’ in the self (Kernberg, 1967). This correlates with the diagnostic boundaries of the DSM-5 that focus on impairments to interpersonal functioning. Arguably, an integrated sense of self is one of the main goals of therapeutic interventions, Stone (2006), argued that the main aim of psychotherapy would be to fuse split aspects of the clients’ psyche and thus their behaviours towards self and (through projection) others, would be resolved. 

Clinicians Experience and Stigma

A diagnosis of BPD can also carry significant stigma. Due to the nature of the condition, clients can present as challenging and create a marginalisation for people associated with the diagnosis. It was also shown that BPD clients received a lower standard of treatment due to professional perception of the manipulative nature of the clients (Droskin, 2002). Professional expecting negative outcomes or even refusing to treat this client population can increase the tendencies of BPD clients to create alienation, devalue relationships and self-harm (Critchfield et all., 2007). This theme of rejection can have a massively negative impact on recovery.

Ethnicity and BPD

As discussed in this literature review, a broken or split sense of self can be considered the core of BPD and the key component that perpetuates the personality disorder. The explored literature on ethnicity is somewhat lacking but highlights those from ethnic backgrounds may have poorer outcomes in terms of therapeutic benefit on average (Beutler, Blatt et al., 2006). However, there seems to be little to no research on the effects of a diagnosis such as BPD on ethnic clients. Arguably, due to cultural/ethnic norms, there is a greater shift and focus from the self to the community, a shift from the I to the We. Given the already fragile sense of self for BPD clients, is also being from an ethnic background, a double marginalisation due to cultural and diagnosis stigma harder to deal with?